Evaluation and Management of Lateral Ligament Injuries of the Elbow

The Problem

The elbow is a complex joint with its stability dependent on both its bony articulations and soft tissue restraints. The lateral collateral ligament (LCL) complex is the soft tissue component that confers stability to varus stress of the elbow joint. The supinator, common extensor origin, anconeus and brachialis provide additional dynamic muscular stabilization of the LCL complex. The LCL origin is from the lateral epicondyle of the distal humerus and consists of four major structures:

Lateral ulnar collateral ligament (LUCL)
Annular ligament
Lateral radial collateral ligament
Accessory lateral collateral ligament
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LCL injury causes the proximal ulna and radius to rotate externally from the humerus with supination/varus stress.

Two main classifications of lateral ligament instability are used:

Posterolateral rotary instability (PLRI): due to insufficiency of the LUCL
Varus instability: global lateral collateral ligament complex insufficiency

The LCL complex typically avulses from its lateral epicondyle, along with laterally based capsule and extensor origin tissue.

Clinical Presentation

Lateral ligament injuries of the elbow typically occur due to a history of trauma in the setting of elbow dislocation. They can also be caused iatrogenically – with a common example being an LCL injury during surgical treatment of lateral epicondylitis. LCL injuries may also be seen following pediatric distal humerus fractures with residual varus malunion and gunstock deformity.

Patients complain of pain with clicking/snapping or locking of the elbow, but can have a painless full arc of motion. Symptoms occur with the forearm in a supinated position, with the elbow in a more extended position. Patients may report a history of recurrent elbow dislocations. Similar to posterior instability in the shoulder, the main complaint is pain rather than a complaint of instability.

Diagnostic Workup

The physical examination begins with inspection for signs of injury such as swelling, and palpation for tenderness. A careful neurological and vascular examination is performed. Elbow range of motion should be tested with care to check for mechanical blocks to motion and/or the presence of crepitus. Careful ligamentous exam is performed for lateral instability with comparisons made to the contralateral uninjured side.

Test varus stress for laxity in 0 and 30 degrees of flexion. Specific tests include:

PLRI pivot shift

Difficult to elicit in an awake patient. Most amenable for examination under anesthesia.

Patient supine with arm forward flexed overhead.

Hold forearm fully supinated with elbow in full extension.

Bring to flexion while applying valgus and supination stress with axial compression.

A positive test results in reduction of the radiocapitellar joint as the elbow is brought to flexion.

Full flexion will reduce proximal radius.

Apprehension with this maneuver can also be considered positive in the appropriate clinical setting since this exam is often difficult to perform while the patient is awake.
Ask patient to push up from chair – apprehension or feeling of instability is considered positive.
Ask patient to do push up on floor – apprehension when approaching full extension is considered positive.

Good quality radiographs are essential – always get a true lateral view. The images are assessed for joint congruency. Fluoroscopy can be useful for stress testing – can apply varus stress and look for joint space widening laterally. MRI is useful for evaluation of ligament ruptures and associated osteochondral injury. Ultrasound is cheaper than MRI, though operator and institution dependent.

Non–Operative Management

In the setting of traumatic/symptomatic lateral ligament injuries of the elbow, there is little role for non-operative management. Immobilization in a position of stability (based on range of motion exam and/or fluoroscopy may be attempted. This often results in elbow stiffness requiring later contracture release; but a stiff stable elbow is a fixable problem, while a chronically unstable elbow is more difficult to treat.

Indications for Surgery

Surgery is indicated for any patient with symptomatic lateral instability/PLRI
Surgical options include:

LCL repair – in the acute setting

LCL reconstruction – in more severe acute, or in chronic setting

Docking technique

Jobe technique

Interference screw technique

Surgical Technique

General Considerations

Supine position is used most often, but based on surgeon preference, a lateral decubitus position with elbow at 90 degrees over a bolster may also be used.
Pneumatic tourniquet.
Lateral incision as described by Kocher – interval between anconeus and extensor carpi ulnaris.

It is not uncommon to find a full avulsion of the LUCL and the common extensor tendon, with bare bone exposure of the lateral epicondyle.
Important concepts for repair/reconstruction.

Appropriately tensioned – test before finalizing fixation with range of motion.

Anatomically based on an isometric point – test with elbow range of motion.

Tensioning should be performed with the elbow at 60 degrees of flexion, and in forced pronation.
It has been recommended to place the humeral origin at the isometric point.

This can be identified by placing a K-wire at the proposed location, wrapping the suture from the lateral ligament complex around the wire multiple times, and ranging the elbow.

The correct isometric point will have consistent tension on the suture.
External fixation is rarely, if ever, necessary in pure laterally based ligamentous elbow injuries, but may play a role in the setting of more severe trauma such as elbow fracture-dislocations or global elbow instability.
Before final tensioning, the elbow should be ranged with tension on the graft to remove creep.

Acute/Repair

If tissue quality/quantity is adequate, repair can be performed.
Identify avulsed ligamentous structures.
May use a suture anchor at the proximal attachment site on the lateral epicondyle.
Place grasping suture (Krakow) within the LCL complex (#2 or #5 nonabsorbable suture).
Tension with forearm in pronation and at 60 degrees of flexion.

Chronic/Reconstruction

Many choices for graft – author preference is palmaris longus autograft or gracilis autograft.

Other options: plantaris or second toe extensor.

While autograft is ideal, allograft of the above is an option as well.

Require approximately 15-20cm of length.
Use a bent Hewson suture passer or appropriate awl to facilitate graft passage.

Jobe Technique

Use a 4mm burr to drill two holes in proximal ulna.

First hole is near the tubercle on the supinator crest.

Second hole is proximal, near the base of the annular ligament (Figure 1).
Drill a 4.5mm hole at LUCL origin in the humerus anteriorly.

On occasion this may require enlargement to allow graft passage.
Drill 3.5mm holes x2 from posterior to connect with the anterior 4.5mm hole.

One starts posterosuperiorly, the other posteroinferiorly.

This will create a “Y” configuration of tunnels within the distal humerus.

Take care to leave a 1cm osseous bridge to avoid fracture.
Place grasping suture through one end of the graft to facilitate graft passage.
Pass graft in a figure-of-eight manner through the drill holes (Figure 2).

This creates a loop of graft over both the ulnar and posterior humeral bone bridges.
Tension and suture the graft ends to themselves along its mid-substance course between the distal humerus and proximal ulna.

May perform a Pulvertaft weave of graft ends together prior to suturing if of sufficient length; however, this may cause a bulky lateral epicondyle (Figure 3).

Docking Technique

Use a 4mm burr to drill two holes in proximal ulna.

First hole is near the tubercle on the supinator crest.

Second hole is proximal, near the base of the annular ligament (Figure 4).
Use a curved awl to create a path between these two tunnels.
Create a 4mm hole at the origin site on the distal humerus, again using the burr.

Depth of 15mm.
Use a small drill bit to create two exit “puncture” holes at the 15mm point.

Make sure to leave at least a 1cm bridge here to avoid fracture.
Use two non-absorbable sutures in a Krakow fashion through reflected capsule for later passage.
Place another Krakow suture through one end of the graft.
Weave graft through ulnar holes in retrograde fashion.
Shuttle the graft suture and capsular suture through the humeral hole using the houston suture passer, exiting through the puncture holes.
Pull the non-sutured end of the graft next to the humeral tunnel, estimating the final length of graft necessary after tensioning.
Mark this point, and place another Krakow suture in this end of the graft at that location.

Excise the excess graft above this stitch.
Shuttle this suture through the puncture holes.
Tension and tie the four pairs of graft suture over the bony tunnel (capsular sutures tied first).

Interference Screw Technique

Place a 5mm drill hole at the ulnar insertion at the sublime tubercle
Drill another 5mm hole at the epicondylar origin site, directed to exit posteriorly.
Fold graft in half to create a double stranded graft.
Place a whip-stitch at both ends of the graft with No. 1 braded suture.
Pull the suture through the cannulated screwdriver for a 5mm x 15mm cannulated interference screw.
Place the graft and interference screw into the ulnar tunnel.
Position the elbow for appropriate tension and maintain constant tension on sutures while placing screw into distal humeral hole.
Use remaining suture ends and a free needle to suture any remaining native tissue to graft tissue for additional fixation.

Pearls and Pitfalls of Technique

Pearls

Be certain of well-reduced elbow before graft tensioning.
Maintain pronated posture of forearm during early rehabilitation to decrease stress on reconstruction.

Pitfalls

Avoid drill hole fractures.
Use tendon of sufficient length.
Do not allow premature return to activity.

Potential Complications

Postoperative stiffness/arthrofibrosis
Postoperative instability
Wound infection
Post-traumatic arthritis
Fracture (through bone bridge)
Cutaneous nerve injury

Post–operative Rehabilitation

Initially placed in a splint with elbow flexed at 90 degrees and in slight pronation.
Splint removed at 2 weeks and sutures removed.
Gentle active range of motion performed in therapy with continued removable brace or hinged elbow brace for 4-6 weeks.

If a hinged brace is used, it must be checked frequently for correct fit, as the hinge tends to migrate distally and severely limit comfort and utility.
Strengthening begins and progresses between 6 weeks to 3 months postoperatively.
Caution patients to avoid varus elbow stress for 6 months after surgery (weight bearing with shoulder in abducted position such as pouring milk from a gallon container).
Return to recreational sports at 6 months.

Outcomes/Evidence in the Literature

Literature Review:

Interference screw fixation restores strength and elbow kinematics comparable to that of native ligament.
Most patients will achieve gross stability after reconstruction, though a loss of terminal extension of 5-15 degrees is not uncommon.
The docking technique as adopted from medial collateral reconstruction techniques, is successful for lateral ulnar collateral reconstruction, with 75% of patients exhibiting stability at mid-term follow-up.

McGuire, D, Bain, GI. “Medial and lateral collateral ligament repair or reconstruction of the elbow”. Oper Tech Orthop. vol. 23. 2013. pp. 205-214.

Reichel, LM, Milam, GS, Sitton, SE, Curry, MC, Melhoff, TL. “Elbow lateral collateral ligament injuries”. J Hand Surg. vol. 38A. 2013. pp. 184-201.

Anakwenze, OA, Kancherla, VK, Iyengar, J, Ahmad, CS, Levine, WN. “Posterolateral rotatory instability of the elbow”. Am J Sports Med. vol. 42. 2014. pp. 485-491.

Thompson, WH, Jobe, FW, Yocum, LA, Pink, MM. “Ulnar collateral ligament reconstruction in athletes: muscle splitting approach without transposition of the ulnar nerve”. J Shoulder Elbow Surg. vol. 10. 2001. pp. 152-157.

Jones, KJ, Dodson, CC, Osbahr, DC, Parisien, RL, Weiland, AJ, Altchek, DW, Allen, AA. “The docking technique for lateral ulnar collateral ligament reconstruction: surgical technique and clinical outcomes”. J Shoulder Elbow Surg. vol. 21. 2012. pp. 389-395.

Ahmad, CS, Lee, TQ, AlAttrache, NS. “Biomechanical evaluation of a new ulnar collateral ligament reconstruction technique with interference screw fixation”. Am Jour Sports Med. vol. 31. 2003. pp. 332-337.

Summary

Lateral elbow instability is a problem that often requires surgical management. It typically occurs in a traumatic setting. Many operative techniques exist as listed in this text, though a single technique has not been shown to be more effective in treatment. Careful history and physical examination is paramount in making the diagnosis. It is important to discuss the nature of the injury and the importance of rehabilitation in treating this difficult orthopaedic problem.

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